Comparison of crestal bone loss and papilla fill after conventional and immediate implant placement: A 12 month clinical and radiographic prospective study

Background The problem of missing teeth persists in all age groups. The main objective of implants in dentistry is to provide a restoration that reconstructs the shape and restores esthetics and functions of edentulous areas. The objectives of this study are to compare the crestal bone level changes and papillary fill after placement of implants in fresh extraction socket, i.e. immediate implant placement, and healed extraction socket, i.e. delayed or conventional implant placement, and to assess other clinical parameters such as modified plaque index (mPI), modified gingival index (mGI) and gingival biotype in between the groups and within the groups. Methods 18 patients were recruited in the study out of which 9 patients received implants as per immediate implant placement protocol (group 1) and 9 patients received implants as per conventional implant placement protocol (group 2). All patients were evaluated for gingival biotype, mPI and mGI and papillary fill was assessed as per Jemt’s papilla score as clinical parameters. Implant site was assessed for radiographic bone loss using Image J software. Statistical analysis was performed using independent t test, paired t test and chi square test. Results At the end of 1 year, results showed that crestal bone loss was seen more in the immediate group than the conventional group. Conventional implants showed better papillary fill than implants placed in fresh extraction sockets. Plaque scores were assessed as per modified plaque index, which showed better results in the conventional group. Modified gingival index was used to assess gingival status which showed better results in the immediate group one year later. Conclusions Findings from the study suggest that crestal bone loss was found to be increased in the immediate group than the conventional group and papillary fill was better in the conventional group than the immediate group. Registration: CTRI ( CTRI/2019/09/021340).

gingival biotype, mPI and mGI and papillary fill was assessed as per Jemt's papilla score as clinical parameters.Implant site was assessed for radiographic bone loss using Image J software.Statistical analysis was performed using independent t test, paired t test and chi square test.

Results
At the end of 1 year, results showed that crestal bone loss was seen more in the immediate group than the conventional group.Conventional implants showed better papillary fill than implants placed in fresh extraction sockets.Plaque scores were assessed as per modified plaque index, which showed better results in the conventional group.Modified gingival index was used to assess gingival status which showed better results in the immediate group one year later.

Conclusions
Findings from the study suggest that crestal bone loss was found to be increased in the immediate group than the conventional group and papillary fill was better in the conventional group than the immediate group.

Introduction
The loss of a single tooth is thought to be a typical esthetic issue that could have psychological effects as well as nonphysiological occlusion, that results due to tipping of the neighboring tooth and supra-eruption of the opposing tooth. 1,2he main objective of implant therapy or modality is to provide a restoration that not only reconstructs the shape but also the esthetics and functions of edentulous areas.Clinical replacement of missing natural teeth with osseointegrated implants has been referred as one of the most notable developments in dentistry. 3,4acement of a single tooth implant can either be done in healed extraction socket/site as a conventional or delayed implant, or can be done in a fresh extraction socket/site as an immediate implant procedure. 5,6Conventionally, implants are placed in healed extraction sites, allowing for a 3-6 month osseointegration period.Immediate implants, on the other hand, are inserted into fresh extraction sockets, reducing treatment time, preserving alveolar bone, and minimizing the edentulous period.This method is favorable because it helps to achieve optimum axial positioning of the implant by using the socket as a reference, shortens the edentulous period of three to six months, and requires fewer surgical visits.The success of single tooth replacement depends on factors such as implant survival, changes in marginal bone level, soft tissue measurements, prosthetic complications, and esthetic criteria.Papillary integrity is crucial, as it protects the adjacent periodontium.Peri-implant bone changes occur due to the creation of a biologic width, and initial bone loss can be attributed to various factors.This study aims to compare crestal bone levels and papillary fill in immediate and conventionally placed single tooth implants.8][9][10][11][12][13][14][15]

Ethics and consent
This clinical trial was approved by the Institutional Ethics Committee, Manipal College of Dental Sciences, Mangaluru (ref no.18120).Initial approval was received on 20 th October 2018 and finalised on 12 th November 2018.Participants provided signed informed consent prior to the start of the study.This trial is also registered with CTRI (CTRI/2019/09/021340).Due to some technical issues with the initial registry, the trial was registered retrospectively.All procedures were conducted in compliance with the Helsinki Declaration 1975.

Procedure
Study participants who reported to the Department of Periodontology, Manipal College of Dental Sciences, Mangalore with the chief complaint of a missing single tooth were selected as participants in this study.The study was conducted from 1 st November 2018 to 1 st December 2020.Before the commencement of the study, the patients were informed of the clinical trial design and were required to sign their informed consent.

Sample size calculation
Using the above formula, the sample size was calculated.Where Z (1-α/2) = Z score for the α power chosen.Z (1-β) = Z score for the power chosen.σ1 = standard deviation of group-1.σ = average standard deviation.d = the minimum difference between in the values with which make clinically relevant impact.With 5% alpha error, 90% power of the study and a clinically significant difference of 0.05 units, the required sample in each group is 9.

Randomization
The investigator (DK) was in charge of enrolling participants and allocating surgical procedures.The coin toss approach was used for randomization.The lead investigator (AR) performed all surgical operations.A masked investigator (NS) assessed the patients during the recall period and was blinded to all the surgical treatments that had been assigned.

REVISED Amendments from Version 1
The new version provides more detailed background information on the importance of the present study.The inclusion and exclusion criteria has been refined along with the methodology to provide more clarity.Additional assisting information has been added in the discussion to support the study.
Any further responses from the reviewers can be found at the end of the article Inclusion criteria for the patients 1. Age group of 18 to 55 years.
5. Availability of follow up.
7. Adequate quality and quantity of bone.
10.If buccal cortical plate gets fractured during the procedure of immediate implant placement, the patient will be included in the conventional group.
Patients were excluded from the study if they: 1. Were pregnant at the time of inclusion.
3. Patients who were not be willing to undergo the treatment.

Defective extraction sockets.
A total of 18 patients with edentulous single tooth were included in the study.Patients of both sexes (7 females and 11 males) in the age range of 18 to 55 years were included in the study.Sex or gender do not impact the bone loss or gain in this study.The study was conducted in a prospective manner and was a comparative clinical trial involving two groups who had a missing single tooth.The patients were those in whom the implants were placed, and prosthesis was yet to be given.
All the implants used were from the MIS SEVEN implant system (see Figures 1 and 2).The Implant MIS seven system features an internal hexagon connection, ensuring an optimal fit between the implant and abutment, minimizing micromovements, and reducing bone resorption.Its interior body is tapered for horizontal bone condensing, possesses sharper threads at the apex, and incorporates a dual thread design with micro-rings to enhance bone-to-implant contact.The surface undergoes sand-blasting and acid etching treatments, creating micro and nano-structures while eliminating various surface contaminants.Conventional abutments of either cement post or screw retained type were used for the prosthesis.In the 18 patients, 18 implants were placed; of which 12 were placed in the maxilla and 6 were placed in the mandible.All the patients were placed on regular maintenance, with all of them being recalled every 1 month, 6 months and 12 months.At every recall visit, oral hygiene instructions like tooth brushing and use of interdental aids were reinforced.The following clinical parameters were assessed at baseline, 6 months and 12 months after cementation of crown (Figures 3 and 4): 1. Jemt papilla index (JPI); 2. modified plaque index (mPI); 3. modified gingival index (mGI); 4. gingival biotype.
Jemt Index (Torsten Jemt, 1997) This index was used to assess the size of the interproximal papillae adjacent to single implant restorations. 16The assessments were made from a reference line through the highest gingival curvatures of the crown restoration on the buccal side and the adjacent permanent tooth.Index scores were given from 0 to 4 based on the amount of papilla present (see Table 1).

Modified Plaque Index (Mombelli et al. 1987)
A mouth mirror and William's periodontal probe were used, after air drying of the implant to assess for presence of plaque by running the probe along the margin.The surfaces examined were four gingival areas of the tooth i.e. distofacial, facial, mesiofacial and lingual surfaces.

Modified Gingival Index (Apse et al. 1991)
A mouth mirror was used to assess the modified gingival index by visual examination on of buccal and palatal/lingual surfaces, without probing.

Gingival biotype
After administration of local anesthesia, an endodontic file with a rubber stopper was penetrated into the facial soft tissue until it reached the bone.Measurements of gingival thickness directly on the midfacial area were obtained 2 mm below the free gingival margin.The thickness of facial soft tissue was equal to the distance between the rubber stopper and the tip of the endodontic file which was recorded by a digital caliper to the nearest 0.1 mm.It is categorized into thick or thin based on the amount of tissue thickness.If it was >1 mm, then it was considered as thick and if it was <1mm, it was considered as thin biotype.

Radiographic technique and measurements
Intraoral radiographs were taken for all patients at baseline, 6 months and 12 months after crown cementation.
A standardized intra oral periapical radiograph (IOPAR) was taken for each selected site using the long cone paralleling technique using a film holder (RINN, XCP, Dentsply Illinois, USA).All radiographs were obtained utilizing an 'E' speed  film (Kodak Carestream Health Inc., New York, USA) mount utilizing a mm grid scale as a standardized stent.These grid scale lines are printed vertically and horizontally at 1mm interval and with bold lines at 5 mm.The factors listed below were taken into account when calculating the degree of bone loss adjacent to the implants.To determine the vertical measures, the fixture abutment junction (FAJ) implant shoulder's horizontal measurement served as a guideline while image analysis software was used for the following radiographic parameters: 1.The most coronal portion of bone that contacts the implant and the vertical distance from the implant's shoulder (FAJ) were given the designation FAJ-I.2. The most coronal portion of bone facing the neighbouring tooth and the vertical distance from the implant's shoulder were referred to as FAJ-Adj.
3. The soft tissue height was measured from the implant's shoulder to the coronal papilla level.
4. The contact point's vertical distance from the bone's crest was denoted as CP-Bone crest.All radiographs were scanned using a scanner (HP Scanjet).All radiographic measurements were carried out by using software, Image J. 17 Image J (Image processing and analysis in Java) is a pure Java image processing program which can measure area, mean, standard deviation, lengths, angles and min or max of selection or entire image.The Image J analysis was carried out as follows: the image was first transferred to the Image J analysis software, then using the straight-line option, a straight line was drawn to measure 1 mm grid and scale was set by converting distance into pixels.Once the distance was set, all the above-mentioned parameters were measured using the same tool and the amount of bone loss that has occurred was then calculated.[20][21][22][23][24][25]

Statistical analysis
No implant was lost during the observational period.2-5).Papilla scores at the end of 1 year showed that distal papilla fill was better in the immediate group The papilla fills up the entire proximal space and is in good harmony with the adjacent papillae 4 The papillae are hyperplastic and cover much of the single implant restoration and/or the adjacent tooth.(with score 3 in 14.3% of patients) than the conventional group (with score 3 in 11.1% of patients) and mesially, scores were better in the conventional group (with score 3 in 22.2% of patients) than the immediate group where none of the patients had a score of 3 on the Jemt papilla index.So, conventional implants showed less bone loss and better papillary fill than implants placed in a fresh extraction socket.Plaque scores were assessed as per modified plaque index (mPI) which showed better results in the conventional group (score 1 in 88.9% of patients) than the immediate group (score 1 in 85.7% of patients).Modified gingival index (mGI) was used to assess gingival status which showed better results in the immediate group (100% of patients showed score 1) than the conventional group (88.9% patients showed score 1 and 11.1% of patients showed score 2) at the end of 1 year.Also, gingival biotype did not appear to affect changes in crestal bone level or papilla fill.Sex or gender of the patient does not impact the bone loss or gain in this study.

Discussion
A crucial indicator for the health of an implant is the quality of the crestal bone.Its preservation is considered an essential indicator for the success of dental implants.Also, the height of the papillae that is related to the interproximal crestal bone contributes to the success of the implant.Thus, papillae preservation height and crestal bone is paramount for fruitful success of the outcome of an implant.Long term studies on the volume of crestal bone loss in the early healing phase, i.e., within one year, generally observe 1.5 mm in the first year, followed by 0.2 mm annually. 26This could be because of occlusal loading forces during mastication and the presence of micro gaps between the implant and placement of the abutment at or apical to the crest, which acts as a plaque retentive area and leads to bone loss.When crestal bone loss occurs, the soft tissue overlying the crestal bone i.e. the papillae would also recede and will lead to plaque accumulation and an unaesthetic appearance.Early implant failure may occur due to the lack of osseointegration occurring within a few weeks to months.Factors contributing to early failure include bone necrosis, bacterial infection, surgical trauma, insufficient initial stability, and premature occlusal loading.In contrast, late failure occurs after a prolonged period of functional loading and is typically associated with infection and excessive mechanical loading. 27 this study, a total of 18 patients were recruited.9 patients received implants as per immediate implant placement protocol (group 1) and 9 patients received implants as per conventional or delayed implant placement protocol (group 2).Astrand et al. 28 used two different implant systems (AstraTech and Branemark system) and showed that there was a difference in the pattern of bone remodeling between the implant systems.This can be attributed to the macro and micro characteristics that vary from one system to another.In this study, we have used the MIS SEVEN implant system which is self-tapping, surface treated and sand blasted to increase surface area, creating both micro and Nano-structures and eliminating surface contaminants.Their geometric design includes dual threads, spiral channels stemming from the apex, micro rings on the implant neck and a variable thread thickness along the implant.The combination of sandblasting and acid etching introduces macro and nano-structures which significantly increases surface area of the implant body for optimal osseointegration.The roughened surface improves bone adhesion, as well as the proliferation and differentiation of osteoblasts.Sand blasted and acid etched surfaces have been substantially proven to maximize the Bone-to-Implant contact, achieving immediate and long lasting osseointegration.It is advantageous to use the same implant system across all patients in the study, as different systems can show different amounts of bone loss.For all the patients, delayed loading protocol was followed, and for all the implants placed, the crown was given after a waiting period of 3-4 months for mandible and 6 months for maxilla. 29,30e bone quality varies in maxilla and mandible and in both anterior and posterior regions.For all the patients, delayed loading protocol was followed, and for all the implants placed, crown was given after waiting period of 3-4 months for mandible and 6 months for maxilla.To avoid the confounding effect of occlusal loading on crestal bone resorption, all patients were given the superstructure according to delayed loading protocol and thus, standardizing the loading protocol.The pattern of bone loss after implant placement varies in maxilla and mandible patients, owing to the difference in the density of the bone as it is more cancellous in the maxilla as compared to the mandible.Longitudinal studies have shown a mean difference of 0.23 mm bone loss for implants placed in the maxilla and mandible. 31,32cessive surgical trauma and thermal injury may lead to thermal necrosis and fibrous encapsulation of implants.
Eriksson and Alberktsson 33 reported that the critical temperature for implant site preparation was 47°C for 1 minute or 40°C for 7 minutes.With overheating, the chance of implant failure increases.In this study, adequate internal irrigation was used to keep temperature of bone to minimum.Sharp drills were used, and osteotomy was performed in a staged manner without jumping the drilling sequence.
The height of the bone around the implant has been measured using a variety of techniques.Compared to conventional methods (using magnifying glass), the computerized method is considered to be superior due to higher accuracy.One of these computerized methods is using Image J analysis software, which has high accuracy and precision along with specificity and sensitivity.][36][37][38] In this study, all the radiographs were taken at baseline, 6 months and 12 months after crown cementation and were taken using paralleling cone technique with grid overlay and analyzed using Image J analysis.All the radiographs were taken using the same exposure settings which are on the X-ray machine and hence, the standardization was maintained.
The present study showed that values of FAJ-I, FAJ-Adj., CP-BC were higher for group 1 than group 2, indicating that higher crestal bone loss was observed in the immediate group (FAJ-I = 2.5 AE 0.3; FAJ-Adj., = 2.09 AE 0.21; CP-BC = 6.06 AE 0.99) than the conventional group (FAJ-I = 2.26 AE 0.62; FAJ-Adj., = 1.9 AE 1.03; CP-BC = 5.94 AE 0.85) and higher soft tissue height values were seen for group 2 (STH = 4.75 AE 0.32) than group 1 (STH = 3.98 AE 1.2), which shows that the conventional group produced better results than the immediate group.Sasi Kumar et al. 39 did a study to measure bone loss in conventional and immediate implant placement and stated that bone loss was seen more in the conventional group (1.28 AE 0.24) than the immediate group (1.10 AE 0.39) mm.This is in contrast to the findings in our study; this could be due to the use of autogenous bone chips harvested from the surroundings, which may have aided in better bone formation in immediate group.Tabrizi et al. 40 demonstrated that the amount of bone loss is significantly (P > 0.05) more in group 2, i.e. conventional (1.6 AE 0.20), than group 1, i.e. immediate, (1.05 AE 0.17) at the 6 month follow up; hence, their results were in contrast to our study.Heinemann et al. 41 on the other hand concluded that there was a non-significant difference between group 1 and group 2 in approximal bone level change during the first year, which was similar with our study.In a study done by Moustafa et al., 42 the immediate loading group showed higher bone loss than the conventional loading group at the end of the 3 year follow up period, which is similar to our findings where the conventional group showed lesser bone loss when compared to the immediate group.Plaque accumulation has been considered as one of the most important causes for crestal bone resorption. 43Formation of plaque on an implant surface is influenced by surface characteristics of the dental implant and abutment material used. 44pilla assessment was done immediately on the day of crown cementation, both in maxillary and mandibular dental implants.The crown cementation was done at 3 months in all the patients, thus, standardizing the papillary assessments.The papillary fill around mesial and distal sides of restored dental implants were assessed clinically by scoring papilla from 0 to 4 as per Jemt's papilla index and by digitizing the images at baseline, 6 months and 12 months.In this study, results showed that in the conventional group, papilla scores (mesially) at 12 months showed complete papilla fill in 22.2% of cases and no complete papillary fill was seen in the immediate group.This could be because 2 patients were lost for 12 month follow up from the immediate group due to COVID-19, which is a limitation of our study.Distally, on evaluating Jemt's papilla score, complete papillary fill was seen in 14.3% of patients in the immediate group and 11.1% in the conventional group.These findings were supported by a study done by Grossberg et al. (2001), 45 in which four patients out of twelve showed complete papilla fill in between the implants.Also, Nariman et al. (2018)'s 46 study found that both mesially and distally, the conventional group (Mesial side = 1.78 and distal side = 1.89) showed better papilla fill than the immediate group (mesial side = 1.20 and distal side = 1.30) which is in contrast to our study.Lee et al. (2005)  47 showed that the soft tissue height in between two adjacent implants was 3.3 AE 0.5 mm.This is in accordance with the study done by Rushad Hosi et al., 46 who also stated that inflammation can lead to false assessment of papillary fill.
The patients in the current study were followed at 6 months and 12 months after crown cementation.The modified plaque and modified gingival index scores (mPI and mGI) were used to assess peri-implant mucosal condition at baseline (i.e. on the day of crown cementation), at 6 months and 12 months.In this study, there was no statistically significant mean plaque score difference found between groups at baseline, 6 months and 12 months.This shows that the patients maintained good oral hygiene at 6 months and gradually decreased at follow up time.This is in accordance with Weber HP et al. (2000) 48 and Renvert S et al. (2009). 49ologic width and biotype are said to influence the peri implant mucosa.In the present study, biotype was divided into two categories: thick and thin.Gingival biotype influences facial marginal gingival level rather than interproximal papillary levels adjacent to dental implants.It was previously reported that peri implant biotype does not influence the peri-implant papilla fill but has an influence on the peri-implant marginal mucosa.A thin biotype is said to lead to increased risk of recession.[52][53][54][55][56][57] Based on existing evidence, there is no statistically significant distinction in terms of implant survival or complications between immediate and delayed implant placement.9][60] There is a clear necessity for randomized controlled trials to assess the optimal timing for dental implant placement following tooth extractions.
A limitation of this study is the smaller sample size.Two patients were lost for 12 months follow up due to COVID-19.The strengths of this study include That the software used in the study to measure bone loss was more accurate than the other graphical methods that had been used in other studies.Additionally, the standardization of implant size and implant system were done in the present study to minimize biasing.

Conclusion
In consideration of the study's shortcomings, it can be said that: • Conventionally placed implants showed less bone loss and better papillary fill than implants placed immediately into fresh extraction sockets at the end of 1 year.
• Gingival biotype had no significant influence with respect to the papilla fill and crestal bone loss irrespective of the technique of implant placement at the end of 1 year.
• Regardless of the technique of implant placement, there was no bone loss after cementation of crown at the end of 1 year.
• In practical terms, clinicians should carefully outweigh the benefits of immediate implant placement in comparison to the elevated risks of crestal bone loss and diminished papillary fill.
• Further high-quality randomized trials are required to assess the impact of immediate versus delayed implant placement on implant survival.The research should extend to include patient-valued outcomes such as aesthetics, function, and psychological wellbeing.Additionally, there is a need for qualitative evidence to explore the experiences and perspectives of dental implant recipients.
Dear Authors, It was suggested that in the results section of the abstract should be more detailed to support the conclusion.Please see the comments below.

Methods and Material:
Please provide more details of the power calculation including the assumed standard deviation and the effect size.Please clarify if the clinically significant difference in this manuscript was defined as 0.05 1.
Please clarify the inclusion criteria for the extraction sockets.Were the defective sockets all included? 2.
Please clarify what standardized position on the soft tissue was measured using an endodontic file.

3.
Please clarify if a standardized stent for the periapical radiographs was used.4.

Conclusions:
It should be added the conclusions of observation were at 1 year.

Are sufficient details of methods and analysis provided to allow replication by others? No
If applicable, is the statistical analysis and its interpretation appropriate?I cannot comment.A qualified statistician is required.

Are all the source data underlying the results available to ensure full reproducibility? No
Are the conclusions drawn adequately supported by the results?Partly Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Implantology and Periodontology
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
1.The introduction may add more detailed background information to give readers a better understanding of the background and importance of the study.
2. Objectives of study can be more clearly defined, such as "compare the effects of immediate and delayed implant on the clinical effects of patients (such as long-term bone mass changes, dental health, aesthetic effects, etc.)." 3.More details can be provided for the method of study, such as the choice of implant type, implant system, and the reason for the surgical methods.4. Will the inclusion in the criteria of extraction of teeth caused by periapical diseases affect the effect of immediate implant? 5. Given that there are many clinical studies on the same subject whose final conclusions are not necessarily consistent, many of the influencing factors (such as the implant system used, the lacking teeth are in the upper or lower jaw, etc.) can analyze the reasons for their inconsistency.This has already been presented in the text, but we suggest a deeper exploration of possible causes and potential clinical significance, rather than just listing the consistent or inconsistent facts.After analyzing these different factors, the need for limiting the conclusions should also be considered.
6.In the conclusion and discussion, the clinical and practical significance of the corresponding findings could be written and divided more clearly, and we suggest more specific data added to make the results more intuitive.
7. The research aim in this paper is comparing immediate implant and delayed implant, but one of the studies mentioned in the discussion part is about immediate loading, so it is doubtful whether it is comparable with the research results in this paper.8.In this paper, the conclusion of sticking crown and gingival biotype does not affect the treatment results, but according to past studies, soft tissue should have certain influence on bone resorption.More literatures searching and discussion is needed.9.In the conclusion part, we can consider further exploring the specific impact of these findings on clinical practice and the future research direction.10.There are many ancient documents in the cited documents.Besides some classic documents, it is necessary to add more recent documents related to the research results of this paper, and the ones in recent 3 years are preferred.

Are sufficient details of methods and analysis provided to allow replication by others? Partly
If applicable, is the statistical analysis and its interpretation appropriate?I cannot comment.A qualified statistician is required.

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: dental implantation I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.Chandni Batra 1 Indiana University, New Albany, Indiana, USA 2 Indiana University, New Albany, Indiana, USA The article under review compares crestal bone loss and papilla fill over 12 years after conventional and immediate implant placement.Evaluations included papilla fill or soft tissue height, modified plaque and gingival index, gingival phenotype and radiographic bone loss.The study results demonstrated better papilla fill and crestal bone preservation with no statistical differences between the groups.Overall, the study is well designed and article well written.It would be beneficial to include the following and make following edits: Include the aim of the study and a sentence on what makes this study different from previously completed similar studies in the introduction. 1.
Inclusion criteria mentions good oral hygiene -how was this defined?(Plaque score/gingival score?) 2.
Inclusion criteria mentions adequate quality/quantity of bone -how was this defined?3.
Terminology gingival biotype can be changed to gingival phenotype as per the 2017 classification system 1 .

4.
Terminology Biologic width can be changed to supracrestal attachment as per 2017 classification system 1 .

5.
Please mention in the results (text) whether the measured differences were significant or not significant for better understanding by readers.

Is the study design appropriate and is the work technically sound? Yes
Are sufficient details of methods and analysis provided to allow replication by others?Yes If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Periodontology and Implant Dentistry I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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Figure 1 .
Figure 1.Operative images of implant placement in immediate group (group 1).

Figure 3 .
Figure 3. Papillary fill in the immediate implant placement group (group 1) at baseline, 6 months and 12 months.

Figure 4 .
Figure 4. Papillary fill in the conventional implant placement group (group 2) at baseline, 6 months and 12 months.

Reviewer Report 18
October 2023 https://doi.org/10.5256/f1000research.144252.r194369© 2023 Batra C.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Two patients from the immediate group were lost at 12 months follow up because of COVID-19.Descriptive statistics, mean and standard deviation were calculated for continuous variables.Independent t-test was used to calculate distribution of implants in arches, mean age, crestal bone values i.e., FAJ-I, FAJ-Adj., soft tissue height and CP-BC between the groups.Intragroup comparison was done using paired t-test.Frequency and percentage were calculated for categorical variables.Chi square test was used to calculate intergroup variables in categorical values.Modified plaque index (mPI), modified gingival index (mGI), Jemt's papilla index (mesial & distal) and gingival biotype was calculated using Chi square test.A value of <0.05 is considered to be statistically significant.Microsoft Excel, SPSS version 1.52t and Image J software were used for analysis.

Table 2 .
The vertical distance from the shoulder of the implant (FAJ) and the most coronal part of bone contacting the implant (FAJ-I) between the groups at baseline, 6 months and 12 months.
*p value is statistically significant.

Table 4 .
Intergroup comparison of soft tissue height at baseline, 6 months and 12 months.

Table 5 .
Intergroup comparison of distance between Contact point -Bone crest (CP -BC) at baseline, 6 months and 12 months.
*p value is statistically significant.